Pathology and Laboratory Medicine Clinical Privileges Last Updated: November 19, 2013

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1 Pathology and Laboratory Medicine Clinical Privileges Last Updated: November 19, 2013 Pathology Clinical Privileges 2013 Service Delivery Organizational Summary AHS Laboratory Services offers a comprehensive range of routine and specialized testing and clinical consultation in the Province of Alberta, Western Canada and North West Territories. These testing services play an essential role in the prevention, diagnosis, treatment and monitoring of disease for the residents of Alberta. Laboratory Services provides an integrated service through AHS laboratories and partnerships with other providers, such as Calgary Laboratory Services (CLS), Dynalife Diagnostic (DLDX), Covenant Health and Medicine Hat Diagnostic Laboratory (MHDL). AHS Provincial Laboratories for Public Health work to maintain and improve the health of Albertans by playing a key role in monitoring, controlling, diagnosing and preventing diseases. The Provincial Laboratory for Public Health team regularly collaborates with other provincial and territorial, national and international health providers and emergency response agencies. More esoteric tests (e.g., those requiring more sophisticated reagents or equipment) tend to be consolidated in Calgary and/or Edmonton (e.g., neonatal metabolic screening). AHS Laboratory Services maintains a test matrix outlining which tests are performed at/consolidated at which sites. Pathologists practice in both metro (Calgary/Edmonton) and non metro locations within Alberta. There is typically a greater demand for generalists in non metro zones/locations, while there tend to be more pathologists with subspeciality expertise in the metro zones. Zone Medical Staff Organization Zone Department(s) Section(s) South Lab Medicine/ Pathology Anatomical Pathology Surgical Pathology Anatomical Pathology Cytopathology Anatomical Pathology Autopsy Pathology Clinical Pathology Clinical Biochemistry Clinical Pathology Hematopathology/Transfusion Medicine Clinical Pathology Microbiology Calgary Pathology and Lab Medicine AP/Cytopathology General Pathology Clinical Biochemistry Hematology/Transfusion Medicine Microbiology Provincial Laboratory Page 1 of 6 November 2013

2 Central Lab Medicine/ Pathology Pathology and Laboratory Medicine Clinical Privileges Last Updated: November 19, 2013 Anatomical Pathology Surgical Pathology Anatomical Pathology Cytopathology Anatomical Pathology Autopsy Pathology Clinical Pathology Clinical Biochemistry Clinical Pathology Hematopathology/Transfusion Medicine Clinical Pathology Microbiology Edmonton North Lab Medicine and Pathology Hospital Health Diagnostics Biochemistry Hematopathology Transfusion Medicine Microbiology HLA/Immunology Anatomical Pathology Surgical Pathology Anatomical Pathology Cytopathology Clinical Pathology Clinical Biochemistry Clinical Pathology Hematopathology/Transfusion Medicine Clinical Pathology Microbiology College of Physicians and Surgeons of Alberta () Requirements The grants practice permits to provide clinical services in Laboratory Medicine. practice permits for Laboratory Medicine also specify a section of practice: Anatomical Pathology; Dermatopathology; Forensic Pathology; Hematological pathology; Neuropathology; General Pathology; Transfusion Medicine; or Medical Microbiology. The College does not grant any additional practice approvals for specific procedures or specialties beyond the practice permit and sections described above. A practice permit from the does not guarantee that an individual will be approved for an AHS Medical Staff appointment or privileges. It is AHS s role and responsibility to screen and evaluate the qualifications of Practitioners in relation to the specific procedures and patient care services they will be providing at specific sites before granting an appointment and clinical privileges. Page 2 of 6 November 2013

3 Description of the AHS List of Pathology Clinical Privileges Pathology and Laboratory Medicine Clinical Privileges Last Updated: November 19, 2013 The AHS Medical Staff Bylaws state that the clinical privileges granted to a Practitioner define the diagnostic or therapeutic s or other Patient care services a Practitioner is deemed competent to perform, the Facility(ies) and Zone(s) within which the Practitioner is eligible to provide care and services to Patients; and the specified AHS Programs and Professional services that the Practitioner is eligible to access. 1 Nothing in this document or the attached List of Pathology Clinical Privileges replaces the processes or requirements set out in the AHS Medical Staff Bylaws and Rules. This document and its attachments are intended to supplement and more fully describe the application of the AHS Bylaws and Rules in the context of Pathology Clinical Privileges. Organization/Interpretation of the Pathology List: Categories of Privileges: The AHS List of Pathology Laboratory Medicine Clinical Privileges describes the categories of pathology privileges applicable to members of the AHS Medical Staff. It is divided into the following categories: Anatomical Pathology (AP); Clinical Pathology (CP); Procedural Privileges; Subspecialty Privileges. If required, each category identifies the subcategories of clinical privileges and/or specific procedures that are included in that category. For each sub category or specified procedure, the list identifies the minimum education, training and/or experience that is expected of AHS Medical Staff members exercising those privileges and the proctoring requirements associated with each category. Privileges in Anatomical and Clinical Pathology include patient diagnosis, ordering and consultation in the listed disciplines, as well as associate ancillary studies (e.g., Flow cytometry is considered to be included under Clinical Pathology Hematopathology privileges). Taken together, AP and CP are sometimes referred to as General Pathology. Anatomical and Clinical Pathology privileges by their nature include activity in subspecialty areas. They differ from Subspecialty Privileges in that individuals with Subspecialty Privileges practice exclusively or almost exclusively in a particular area (see description of Subspecialty Privileges below). 1 AHS Medical Staff Bylaws Page 3 of 6 November 2013

4 Pathology and Laboratory Medicine Clinical Privileges Last Updated: November 19, 2013 Procedural Privileges: These privileges reflect procedures/clinical responsibilities requiring additional training and/or experience. The current list of procedural privileges relate to the collection of samples by the procedures listed. Subspecialty Privileges are applicable in cases where an individuals practice is exclusive or almost exclusive to the particular category. They reflect clinical responsibilities requiring a level of training generally associated with individuals who have completed a fellowship program (or equivalent) in the requested subspecialty. Minimum Education and Training Requirements: The Minimum Education and Training Requirements set out in the AHS List of Pathology and Laboratory Medicine Clinical Privileges are as follows: 1. Appropriate licensure with the College of Physicians and Surgeons of Alberta, AND 2. Credentials satisfactory 2 to the Zone Clinical Department Head (ZCDH), Zone Application Review Committee (ZARC) and/or the Chief Medical Officer (CMO), including: o Successful completion of a Royal College of Physicians and Surgeons of Canada (RCPSC) accredited residency program and fellowship in the RCPSC (FRCPC); OR o Equivalent international training and certification satisfactory to the ZCDH, ZARC and/or CMO. These are minimum requirements. The ZCDH, ZARC and/or the CMO may determine that additional education, training or experience is required. The ZCDH, ZARC and/or CMO may also determine that an individual has developed competency in a particular area, without having completed a fellowship in that area, through an equivalent combination of education, training and experience. The specific residency programs and fellowships required for AHS pathology privileges varies by privilege category and are identified in the AHS List of Pathology Clinical Privileges. Certificant of the Collège des médecins du Québec is considered to be equivalent to Fellow of the Royal College of Physicians and Surgeons of Canada (FRCPC). Non pathologist MDs who are members of the AHS Medical Staff may be granted pathology privileges if they meet the defined minimum training and education requirements outlined on 2 In determining whether credentials are satisfactory, the ZCDH, ZARC and CMO may consider experience and currency of training and certification as relevant factors. Page 4 of 6 November 2013

5 Pathology and Laboratory Medicine Clinical Privileges Last Updated: November 19, 2013 the AHS List of Pathology Privileges. Examples of non pathologist MD s who might require pathology clinical privileges may include: Immunologists; Clinical hematologists. Non physicians: There is a special case that arises in Laboratory Medicine in which nonphysicians who are board certified clinical doctoral scientists or PhDs fill Medical Leadership roles in which they oversee laboratory physicians. By virtue of filling a Medical Leadership role, these individuals must be appointed to the AHS Medical Staff. When this occurs, their clinical privileges will be defined by the clinical responsibilities encompassed in their AHS employment terms and conditions. Minimum education, training and experience requirements will also reflect the minimum education, training and experience required by their AHS employment terms and conditions. : The list also identifies the proctoring requirements associated with each privilege category. Proctoring can be defined as follows: The term proctor is often used to mean observe, supervise, mentor, monitor, or directly assess proctoring reflects a process by which an individual is reviewed and evaluated over time to ensure competence, and proctor identifies the person performing the assessment. The Medical Staff Handbook, A Guide to Joint Commission Standards, Second Edition. Proctoring is a process of direct observation that allows for the focused evaluation of current physician competency in carrying out actual clinical care and takes both cognitive and procedural abilities into account. If the proctor observes potential or imminent patient harm during the proctoring process, it may be ethically appropriate for him or her to intervene. Proctoring and FPPE: Strategies for Verifying Physician Competence, Second Edition. Robert J. Marder, MD, CMSL, and Mark A. Smith, MD, MBA, CMSL. In general, successful quality assurance plan applicable to the individual s area of practice is required. Detailed requirements for each privilege category are identified in the AHS List of Pathology and Laboratory Medicine Clinical Privileges (Appendix 1). Sites of Privileges: A delineation of the sites of clinical activity is a required component of clinical privileges (AHS Medical Staff Bylaws, 3.2.1(c) and 3.2.7). The site of clinical activity for pathology clinical privileges is the site (or sites) from which a pathologist provides service. Sites of clinical privileges will not include all sites to which a Page 5 of 6 November 2013

6 Pathology and Laboratory Medicine Clinical Privileges Last Updated: November 19, 2013 pathologist provides services. In other words, clinical privileges will reflect the site (or sites) where a pathologist is physically located when providing clinical services. A pathologist may have clinical privileges at multiple sites if they travel to multiple sites to review cases/slides or perform procedures. Example #1: Pathologist A is located at the Red Deer Regional Hospital. He/she reviews cases/slides from that hospital as well as others from multiple sites across the Central Zone. He/she provides consultation and advice to multiple sites across the Central Zone. Site of privileges = Red Deer Regional Hospital. Example #2: Pathologist B is located primarily at the University Hospital but also works out of the Misericordia Community Hospital a certain number of days each month. He/she reviews cases/slides from both of those hospitals as well as from other hospitals/sites within the Edmonton Zone and across Alberta. Site(s) of clinical privileges = University Hospital and Misericordia Hospital. Clinical privileges in pathology include the ability/responsibility to provide services like clinical consultation and advice to sites other than the site(s) at which a pathologist is located. Review of the Pathology Clinical Privileges List: This list will be reviewed by the clinical department a minimum of every two years (AHS Medical Staff Rules, 3.4.3(f)(ii)). This would put the deadline for the next review at December Privilege List and Forms Appendix 1: Appendix 2: Request form for pathology privileges (new or change) In development Page 6 of 6 November 2013

7 Description Anatomical Pathology: Patient diagnosis, ordering, and consultation in the following disciplines and associate ancillary studies. / Surgical Pathology Cytopathology Autopsy Pathology AP AP AP (Note: These are minimum requirements. The ZCDH, ZARC and/or CMO may determine that additional credentials are required.) of Alberta (), AND program in Anatomical or General Pathology and is a fellow of the Royal College of Physicians and Surgeons of Canada (FRCPC) in Anatomical or General Pathology, OR b. equivalent international training and certification. of Alberta, AND program in Anatomical or General Pathology and is a fellow of the Royal College of Physicians and Surgeons of Canada (FRCPC) in Anatomical or General Pathology, OR b. equivalent international training and certification. of Alberta, AND program in Anatomical Pathology, General Pathology or Neuropathology and is a fellow of the Royal College of Physicians and Surgeons of Canada (FRCPC) in Anatomical Pathology, General Pathology or Neuropathology, OR b. equivalent international training and certification. The ZCDH or designate will be responsible for ensuring that the following proctoring takes place: (1) Locums and new hires: (a) 100% of reports reviewed prospectively to determine level of compliance with site policies, procedures and reporting practices, and (b) At least 10% internal review of slides. Assessment Period: New hires - first two weeks new hire arrives and again 6-8 weeks later. Locums - first 2 days a locum is on site. (Source: Laboratory Orientation of New Pathologist Hires / New Locums to a Site Policy 2013) (2) All pathologists: Ongoing successful provincial Anatomical Pathology Quality Assurance Plan. Appendix 1: Last Updated: September 4, 2013 Page 1 of 8

8 Description Clinical Pathology: Patient diagnosis, ordering, and consultation in the following disciplines. / Medical Biochemistry Hematopathology and/or Transfusion Medicine CP CP (Note: These are minimum requirements. The ZCDH, ZARC and/or CMO may determine that additional credentials are required.) program in General Pathology, Medical Biochemistry or Anatomical Pathology and is a fellow of the Royal College of Physicians and Surgeons of Canada (FRCPC) in General Pathology, Medical Biochemistry or Anatomical Pathology, OR equivalent international training and certification. In the case of individuals with residency training and FRCPC in Anatomical Pathology, a combination of education, training and experience in Medical Biochemistry satisfactory to the ZCDH, ZARC and CMO will also be required. program in General Pathology, Hematopathology or Anatomical Pathology and is a fellow of the Royal College of Physicians and Surgeons of Canada (FRCPC) in General Pathology, Hematopathology or Anatomical Pathology, OR b. equivalent international training and certification.. In the case of individuals with residency training and FRCPC in Anatomical Pathology, a combination of education, training and experience in Hematopathology and/or Transfusion Medicine/Blood Bank satisfactory to the ZCDH, ZARC and CMO will also be required. The ZCDH or designate will be responsible for ensuring that the following proctoring takes place: (1) Locums and new hires: Successful applicable clinical pathology quality (2) All pathologists: Ongoing successful applicable clinical pathology quality *As of the date these proctoring requirements were approved by the Pathology Privileging Working Group (August 23, 2013), a quality assurance plan for this area had not yet been developed. Appendix 1: Last Updated: September 4, 2013 Page 2 of 8

9 Description Clinical Pathology (cont d): Patient diagnosis, ordering, and consultation in the following disciplines. / Medical Microbiology CP (Note: These are minimum requirements. The ZCDH, ZARC and/or CMO may determine that additional credentials are required.) (2) One of the following that is satisfactory to the ZCDH, ZARC and/or program in General Pathology, Medical Microbiology or Anatomical Pathology and is a fellow of the Royal College of Physicians and Surgeons of Canada (FRCPC) in General Pathology, Medical Microbiology or Anatomical Pathology, OR b. equivalent international training and certification. In the case of individuals with residency training and FRCPC in Anatomical Pathology, a combination of education, training and experience in Medical Microbiology satisfactory to the ZCDH, ZARC and CMO will also be required. The ZCDH or designate will be responsible for ensuring that the following proctoring takes place: (1) Locums and new hires: Successful applicable clinical pathology quality (2) All pathologists: Ongoing successful applicable clinical pathology quality *As of the date these proctoring requirements were approved by the Pathology Privileging Working Group (August 23, 2013), a quality assurance plan for this area had not yet been developed. Appendix 1: Last Updated: September 4, 2013 Page 3 of 8

10 Description Procedural Privileges: These privileges are requested/ granted for the collection of samples by the procedures listed. / Bone Marrow Aspiration and Biopsy FNA (Fine Needle Aspiration) Biopsy: Superficial CP or HP AP or GP (Note: These are minimum requirements. The ZCDH, ZARC and/or CMO may determine that additional credentials are required.) program in General Pathology, Hematopathology or Anatomical Pathology and is a fellow of the Royal College of Physicians and Surgeons of Canada (FRCPC) in General Pathology, Hematopathology or Anatomical Pathology, OR b. equivalent international training and certification. In the case of individuals with residency training and FRCPC Anatomical Pathology, a combination of education, training and experience in Bone Marrow Aspiration and Biopsy satisfactory to the ZCDH, ZARC and CMO will also be required. program in Anatomical or General Pathology and is a fellow of the Royal College of Physicians and Surgeons of Canada (FRCPC) in Anatomical or General Pathology, OR b. equivalent international training and certification, AND (3) One of the following that is satisfactory to the ZCDH, ZARC and/or a. a Cytopathology Fellowship, OR b. an equivalent combination of education and experience in Superficial FNA Biopsy. The ZCDH or designate will be responsible for ensuring that the following proctoring takes place: (1) Locums and new hires: Perform a specified number of procedures under the supervision of a physician with experience in that procedure, and successful participation in the applicable quality (2) All pathologists: Ongoing successful applicable quality *As of the date these proctoring requirements were approved by the Pathology Privileging Working Group (August 23, 2013), a quality assurance plan for this area had not yet been developed. Appendix 1: Last Updated: September 4, 2013 Page 4 of 8

11 Description Procedural Privileges: These privileges are requested/ granted for the collection of samples by the procedures listed. / FNA Biopsy: Deep FNA Biopsy: Ultrasound Guided AP or GP AP or GP (Note: These are minimum requirements. The ZCDH, ZARC and/or CMO may determine that additional credentials are required.) program in Anatomical or General Pathology and is a fellow of the Royal College of Physicians and Surgeons of Canada (FRCPC) in Anatomical or General Pathology, OR b. equivalent international training and certification AND (3) One of the following that is satisfactory to the ZCDH, ZARC and/or a. and a Cytopathology Fellowship, OR b. an equivalent combination of education and experience in Deep FNA Biopsy. program in Anatomical or General Pathology and is a fellow of the Royal College of Physicians and Surgeons of Canada (FRCPC) in Anatomical or General Pathology, OR b. equivalent international training and certification. AND (3) One of the following that is satisfactory to the ZCDH, ZARC and/or a. a Cytopathology Fellowship, OR b. an equivalent combination of education and experience in Ultrasound Guided FNA Biopsy. The ZCDH or designate will be responsible for ensuring that the following proctoring takes place: (1) Locums and new hires: Perform a specified number of procedures under the supervision of a physician with experience in that procedure, and successful participation in the applicable quality (2) All pathologists: Ongoing successful applicable quality *As of the date these proctoring requirements were approved by the Pathology Privileging Working Group (August 23, 2013), a quality assurance plan for this area had not yet been developed. Appendix 1: Last Updated: September 4, 2013 Page 5 of 8

12 Description Subspecialty Privileges: These categories would be selected/ approved in cases where an individuals' practice is exclusive or almost exclusive to the category. / Neuropathology Dermatopathology AP or NP AP or GP (Note: These are minimum requirements. The ZCDH, ZARC and/or CMO may determine that additional credentials are required.) (2) One of the following satisfactory to ZCDH, ZARC and/or program in Neuropathology and is a fellow of the Royal College of Physicians and Surgeons of Canada (FRCPC) in Neuropathology, OR b. equivalent international training and certification in Neuropathology, OR c. successful completion of a RCPSC-accredited residency and FRCPC in Anatomical Pathology OR equivalent international training and certification in Anatomical Pathology plus an equivalent combination of education and experience in Neuropathology. (2) One of the following satisfactory to the ZCDH, ZARC and/or program in Anatomical Pathology, General Pathology or Dermatology and is a fellow of the Royal College of Physicians and Surgeons of Canada (FRCPC) in Anatomical Pathology, General Pathology or Dermatology, OR b. equivalent international training and certification, AND (3) One of the following: a. additional fellowship training of at least one year in Dermatopathology, OR b. an equivalent combination of education and experience in Dermatopathology. The ZCDH or designate will be responsible for ensuring the following proctoring takes place: (1) Locums and new hires: ongoing successful applicable quality assurance plan for the subspecialty area as it is developed.* (2) All pathologists: ongoing successful applicable quality assurance plan for the subspecialty area as it is developed.* *As of the date these proctoring requirements were approved by the Pathology Privileging Working Group (August 23, 2013), a quality assurance plan for this area had not yet been developed. Appendix 1: Last Updated: September 4, 2013 Page 6 of 8

13 Description Subspecialty Privileges: These categories would be selected/ approved in cases where an individuals' practice is exclusive or almost exclusive to the category. / Forensic Pathology Pediatric Pathology AP, GP or FP AP or GP (Note: These are minimum requirements. The ZCDH, ZARC and/or CMO may determine that additional credentials are required.) CMO : program in Anatomical or General Pathology and is a fellow of the Royal College of Physicians and Surgeons of Canada (FRCPC) in Anatomical or General Pathology, OR b. equivalent international training and certification, AND (3) One of the following: a. additional fellowship training of at least one year in Forensic pathology, OR b. an equivalent combination of education and experience in Forensic Pathology. (2) One of the following that is satisfactory to the ZCDH, ZARC and/or program in Anatomical or General Pathology and is a fellow of the Royal College of Physicians and Surgeons of Canada (FRCPC) in Anatomical or General Pathology, OR b. equivalent international training and certification, AND (3) One of the following: a. additional fellowship training of at least one year in Pediatric Pathology, OR b. an equivalent combination of education and experience in Pediatric Pathology. The ZCDH or designate will be responsible for ensuring the following proctoring takes place: (1) Locums and new hires: ongoing successful applicable quality assurance plan for the subspecialty area as it is developed.* (2) All pathologists: ongoing successful applicable quality assurance plan for the subspecialty area as it is developed.* *As of the date these proctoring requirements were approved by the Pathology Privileging Working Group (August 23, 2013), a quality assurance plan for this area had not yet been developed. Appendix 1: Last Updated: September 4, 2013 Page 7 of 8

14 Description Subspecialty Privileges: These categories would be selected/ approved in cases where an individuals' practice is exclusive or almost exclusive to the category. / Hematopathology and/or Transfusion Medicine AP,GP, HP (Note: These are minimum requirements. The ZCDH, ZARC and/or CMO may determine that additional credentials are required.) (2) One of the following satisfactory to the ZCDH, ZARC and/or program in Anatomical Pathology, General Pathology or Hematopathology and is a fellow of the Royal College of Physicians and Surgeons of Canada (FRCPC) in Anatomical, General or Hematopathology, OR b. successful completion of a RCPSC-accredited residency program in an appropriate medical/surgical specialty and is a fellow of the Royal College of Physicians and Surgeons of Canada (FRCPC) in an appropriate medical/surgical specialty, OR c. equivalent international training and certification, AND (3) One of the following: a. additional fellowship training of at least one year in Transfusion Medicine or Hematopathology, OR b. an equivalent combination of education and experience in Transfusion Medicine or Hematopathology. The ZCDH or designate will be responsible for ensuring the following proctoring takes place: (1) Locums and new hires: ongoing successful applicable quality assurance plan for the subspecialty area as it is developed.* (2) All pathologists: ongoing successful applicable quality assurance plan for the subspecialty area as it is developed.* *As of the date these proctoring requirements were approved by the Pathology Privileging Working Group (August 23, 2013), a quality assurance plan for this area had not yet been developed. Cytopathology AP No (2) One of the following that is satisfactory to the ZCDH, ZARC and/or program in Anatomical or General Pathology and is a fellow of the Royal College of Physicians and Surgeons of Canada (FRCPC) in Anatomical or General Pathology, OR b. equivalent international training and certification, AND (3) One of the following: a. additional fellowship training of at least one year in Cytopathology, OR b. an equivalent combination of education and experience in Cytopathology. Appendix 1: Last Updated: September 4, 2013 Page 8 of 8